This is a fully remote position. Relocation is not required.

HMS is seeking a medical record reviewer to remotely conduct reviews of clinical records to determine adherence to Medicare claims payment and coverage requirements and to identify instances of fraud, waste, and abuse. The medical record reviewer, under the direction of the Medical Director and Medical Review Manager, examines medical record documentation to identify and document the accuracy and consistency of coverage, coding, billing, and payment policies in accordance with NCD and LCD requirements and Program Integrity Manual programs.

Education/Licenses/Experience

• Board Certified in Nursing and licensed to practice nursing in the United States.
• Must be a licensed registered nurse (RN)
• A minimum of three (3) years of experience reviewing medical records to determine proper application of coverage policy.
• Extensive task-specific knowledge of the Medicare program, particularly the coverage and payment rules and coverage requirements.
• Extensive knowledge of medical terminology, ICD-10, and CPT coding requirements
• Experience in the analysis and processing of Medicare claims and clinical review judgment is required.
• A minimum of one year of experience in the medical review processes in one or more of the following entities: MACs, SMRC, CERT, QICs and BFCC-QIOs.
• Certified coder a plus (AHIMA, AAPC)

Program Description

The Centers for Medicare & Medicaid Services (CMS) collaborate with contractors to determine compliance with Medicare coverage, coding, payment, and billing policies and identification of potential fraud, waste, or abuse.

EOE STATEMENT: Healthcare Management Solutions, LLC has established an Affirmative Action Plan. HMS is deeply committed to the concept and practices associated with equal opportunity and affirmative action in all aspects of employment. HMS makes clear that all applicants will be treated without regard to race, color, sex, religion, national origin, age, disability, genetic information, sexual orientation, ancestry, marital status, changes in marital status, pregnancy or parenthood, gender, or gender identity or expression, military or veteran status, political affiliation, or any other protected characteristics under applicable law when the reasonable demands of the position(s) do not require distinction on the basis of age, disability, sex, marital status, changes in marital status, pregnancy, or parenthood.

This company does not tolerate unlawful discrimination in its employment practices. We recognize the value of diversity in our workforce and encourage all qualified candidates to apply. We thank all candidates who choose to apply, however, only those selected for a further interview will be contacted.

Equal Opportunity Employer/M/F/Vet/Disabled. HMS is an EEO/AA/E-Verify compliant and drug free workplace employer.